Healthcare Provider Details

I. General information

NPI: 1750898045
Provider Name (Legal Business Name): SAMSON RILEY SAVILLE LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2018
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date: 11/09/2020
Reactivation Date: 10/25/2022

III. Provider practice location address

203 MAIN ST
MIDDLETOWN CT
06457
US

IV. Provider business mailing address

203 E MAIN ST
MIDDLETOWN CT
06457-4402
US

V. Phone/Fax

Practice location:
  • Phone: 869-975-7455
  • Fax:
Mailing address:
  • Phone: 869-975-7455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6527
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: